The New Heath Care

What are the most common misconceptions about the Affordable Care Act? A lot of people think that because it’s called Obamacare, it’s only signed by Obama and it’s just going to go away with the next president. They don’t understand the whole governmental process, that it went through the House and the Senate. One of the other misconceptions is about the tax credits and how that works. A lot of people who are looking at it initially don’t understand that they’re eligible for tax credits, so they’re getting pretty high quotes for their premiums, but don’t understand that they’re going to get financial assistance. It varies based on your income, but it’s available for anyone with an income within 100 to 450 percent of the federal poverty level.

What do you think are the weakest points of the Affordable Care Act? In terms of the implementation of the law, the website obviously. I think there was not enough content on the website to help people make informed decisions about which insurance was the best for them. A lot of people just selected the lowest plan because in a lot of cases they can get a $0 premium on that, which seems appealing to them, but they don’t understand that that plan also has a $6,000 deductible that has to be met, so people making $18,000 to $20,000 can’t actually afford to use the insurance.

What about the strongest points of the law? I spoke to a guy last week who was incarcerated because one of the provisions of his child support was that he needed to provide insurance for a child who he does not have custody of, and he couldn’t figure out how to do that. I talked him through it, and he was so happy that he wasn’t going to wind up going back in jail. We talk to people who are terminally ill and cancer patients who have never been able to get insurance because of the preexisting conditions. We actually have to show it to them in writing because they don’t want to take our word for it that you can admit you have cancer or AIDS and still get covered.

What are the options for people below the minimum income level for the exchange? While the actual Affordable Care Act does not have anything designed for them, there is a growing movement in Missouri for a ballot initiative for Medicaid expansion. The Missouri legislature voted against it, but the ballot initiative would leave it up to popular vote. I will say that Mercy Hospital does have other options as well.

Who do you think the Affordable Care Act benefits most? It really benefits people who are getting close to retirement age, who are maybe on fixed incomes and don’t necessarily have insurance set up. People with preexisting conditions is a big one, too. Young couples who are just starting out, who don’t have access to insurance through their employer, are also benefited.

How has it affected overall insurance premiums? People who are getting financial assistance are seeing lower premiums. In terms of the overall cost of health care, it’s too early to tell. It’s projected to come down because more people are going to be getting insurance, so medical providers have to keep costs down to remain competitive. I believe that maybe in five or 10 years, the overall cost of health care will go down and the quality of health care will improve, because there will be a larger pool of people who are sick with health insurance, so doctors are going to be getting more experience.

How has the Missouri legislature affected the application of Medicaid? They voted against the Medicaid expansion. It was supposed to pick up the slack between where each state’s individual Medicaid program was and bring it up to meet where the Affordable Care Act takes over. In Missouri, you basically have to be pregnant or disabled to get Medicaid, so Missouri is one of the more difficult states to get it. Other states have provisions for people who are lower income or between jobs and things like that. The Medicaid program is state to state so it changes dramatically.

Are you seeing any trends in Missouri? Once people actually get financial assistance and see [the specifics], they tend to be a lot happier, even the people who tend to be skeptical when they come in. I’ll tell you that the program is not going to help 100 percent of the people—no program is going to. The vast majority of people we see are coming out noticeably better, some are slightly better, and some are way better. I have not spoken to a single person yet who is worse off or has been directly hurt by this. I know some people will suggest there might be small-business owners who are hurt by it. I think you have to look at the scenario a certain way to even assume those people are going backward. For example, small-business owners do have to pay a portion of their employees’ health insurance, but they’re also having healthier employees who are showing up for work more often and being more productive. You can make the claim that it’s better or worse, but you have to adjust what details you include in the conversation to fit, as opposed to taking a look at the whole picture.

Can you explain the tax penalties for not enrolling? It’s $95 per adult and $45 per child up to $285 per family, or 1 percent of your income, whichever is greater—a lot of people don’t realize that in most cases the greater amount is going to be the 1 percent of your income. It’s going to be adjusted onto the income tax that’s filed next year, and that leads to the ridiculous notion that people who don’t pay income taxes can’t be penalized on their taxes, and that’s because the people below the tax filing threshold are exempt, so they don’t actually have to pay the penalty. The tax credits can also be adjusted or given out in the same manner. There is an option where you can receive the financial assistance each month to lower your premium, or you can get that at the end. For people who don't estimate their income accurately, who either receive too much assistance or not enough assistance, that will also be adjusted at tax time. There are also certain hardship cases in which people can be exempt from the penalty.

Are there some people who have to re-apply to their existing insurance? There’s an open enrollment period the same way you would do it for Medicaid or job-based insurance. Starting November 15, everybody will have to enroll for next year. The way that it’s slated to work is that people will have to re-enroll every year. They can change whatever plan they’re in and the provider. The plans that they have this year may not even be there next year. It seems like there are going to be additional plans and providers in Missouri. Right now there are only two providers available, and I think that there are going to be more next year, which might actually lead to lower premiums because of the competition. It’s looking like we’re going to get even better options next year.

What’s the most common piece of advice you give people? I advise people to write down how many times they anticipate going to their primary-care physician in a year. If they have any dangerous hobbies, plan a trip to the emergency room. Try to run the numbers for each plan you’re looking at to find out how much it’s going to cost you to actually use, to not just necessarily choose the plan with the lowest premium or the lowest deductible. I also advise people to use the insurance. There’s lots of preventative stuff like mammograms, pap smears, colonoscopies, check-ups, and vaccinations—most of which are free. In some cases, there are also programs to help people quit smoking and behavioral-health benefits.

How do you anticipate the law changing? I think there’s going to be more transparency between insurance companies and certified application counselors. There’s a lot of information that the insurance companies are not coming out with. As we progress, you will see more transparency there. People who have more of the complicated cases, as we get more exposure, some of those areas will smooth out. For example, right now, all of the children’s applications are automatically sent to Medicaid. There are parents who, for whatever reason, want them denied. I think people are going to have more say in how their applications are handled. I think the system now is designed to be a one-size-fits-all kind of system, and it’s not. But I think those things will be smoothed out as we go.

Untangling the red tape

As a certified application counselor for the Mercy Coverage Assistance Program (855-900-4140, mercy.net/the-affordable-care-act), Craig Piagari devotes his days to helping Missourians better understand the Affordable Care Act. He listens to their stories, financial situations, and medical histories. Then he provides them with vital information about health-insurance plans and financial assistance.